© 2012 Springer-Verlag London Limited. Early cancer can be considered to be malignant disease confined to the muscularis propria of the colon or rectum. The real challenge in early cancer is to differentiate those patients who truly have early disease from those with a primary tumor confined to the bowel wall and metastatic disease. The challenge is significant because in early cancer, nodal metastatic disease is often microscopic. If we were able to exclude metastatic disease, treatment decisions would be relatively simple. If the lesion were excised luminally, by polypectomy, EMR or TEMS, the only consideration post resection would be whether there was an adequate excision margin on histological examination.